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Form Re f. No. Vers ion No.

Page

FOR-FSD-3E 2 1

FORM 3-E

Refund Application Form


Student ID Nationality : :

Ple ase complete all the re quire d fie lds & s ubmit to CASHIER COUNTER 6 OR 7 failing which your re fund maybe de laye d. For Stude nt Hous ing re funds , you s hould contact Stude nt Hous ing De partme nt.
Student Name Contact No Course : : :

E-Mail Address :

I wish to request refund for (please tick one box): Course Fee Ove rpayment for Semester Personal Bond & Hospitalization Deposit Others (Please specify) Reason for requesting refund: Request mode of payment (please tick one box): Direct Bank In (Below RM10,000) Telegraphic Transfer (TT) in (fo reign currency) Cheque (above RM10,000) Year

* Please co mplete the d etails below. Cost of bank charg es fo r telegraphic tran sfer shall be borne by the students. Fo reign currency T/T shall be translated at the p revailing exchange rate on the day of bank tran saction. Penalty of RM10 will be charged for bounced ba ck transa ction due to mismatch of information provided. Payee Name
St ud ent s Name (As stated in Bank Account)

OR Payee Name : Fa t hers / M ot hers


Name (As stated in Bank Account)

Payee IC No
(for Malaysian student)

Payee Passport No.


(for Non- Malaysian student )

Bank Account No Bank Name Bank Address : :

Bank Swift Code : ___ (International Bank TT only) Signature : Name :

Date

For further enquiries, p lease contact the Ca shiers Office, Gr d. Flr, Build ing Heron 1 at 085-4 4388 5 or email fin ance@curt in.edu.my

O ffic e Us e Only :
Checklist: Items Student Details Payment Mode Payee Name Bank Details Completed Yes / No Yes / No Yes / No Yes / No Remarks

Date Received :

Receiv ed By :

---------------------Na me :